Infection
Superficial infection of stagnant mucus is common and usually resolves with douching. Occasionally, staphylococci multiply in a sump of mucopus that collects in the maxillary sinus and this is slow to clear with douching alone Fig. 12.29a, b . Topical nasal mupirocin ointment sniffed up liberally after douching six times a day for 3 weeks can make a dramatic difference in these patients. Infection spreading into the soft tissues is rare. If the patient has increasing pain 1-3 days after surgery...
Indications for MRI
The prevalence of incidental changes on MRI is so great that the technique is of little use in the diagnosis of rhinosinusitis Cooke and Hadley, 1991 . A comparison between a T2-weighted image fluid bright , a T1-weighted image fluid dark , and aT1-weighted image with nonionic contrast provides useful information about soft-tissue lesions Fig. 7.8a-c . This is particularly helpful in defining the boundary of pathology in relation to the dura, orbital apex, or optic nerve. MRI is unable to...
Surgical Anatomy Vzx
The vomer consistently joins the sphenoid in the mid-line and this is a very reliable landmark. The sphenoid intersinus septum is often asymmetric gt 75 and the preoperative CT scans should be studied before operating. The degree of pneumatization of the sphenoid also varies a great deal Lang, 1989 . Axial cuts complement coronal sections and sagittal reconstruction helps Fig. 14.63 . The natural sphenoid ostium is relatively high in the posterior wall of the sphenoid and is often placed at the...
Indications Dys
The primary indication for having a good reason to instrument the frontal recess is when Maximum medical treatment has failed to help frontal sinus symptoms. A partial anterior ethmoidectomy has not succeeded. Fig. 5.42 a Preoperative CT scan of aspergillosis of the frontal sinus and b CT scan after a type II frontal sinusotomy. Fig. 5.42 a Preoperative CT scan of aspergillosis of the frontal sinus and b CT scan after a type II frontal sinusotomy. Fig. 5.43 a Preoperative CT scan of an osteoma...
Advances in Medical Management
It is said that to be a good surgeon you also have to be a good physician. Surgical maneuvers cannot cure the majority of patients with noninfective nasal polyps, any more than they can cure allergic rhinitis. Advances in instrumentation, computer-aided surgery, and optics may refine surgical techniques, but it seems likely that the main advances will come through research into the etiology and pathological mechanisms of allergic and idiopathic rhinitis and nasal polyposis, and the development...
Surgical Technique Svt
Endonasal DCR can be done under local or general anesthesia. It is possible to open the lacrimal sac en-donasally with either conventional instruments or a laser. The laser procedure has the advantage that it can be done more readily as a day-stay procedure as there is a minimal amount of bleeding. The disadvantages of the laser are its expense, the precautions that need to be taken, and the fact that the results are not as good as with conventional instruments. One technique that will help the...
Sphenoid Sinus Clivus and Cavernous Sinus
It is essential to know the pathology, to have detailed imaging, and to have weighed the pros and cons in removing benign lesions in this area Fig 15.52 a, b . They often present late when there are cranial nerve or eye signs and they are often not completely resectable. The benefit of debulking many of these lesions, whose troublesome margins are producing the symptoms, is not always clear. It is often the edges of these lesions that are spreading through the skull base that cannot be...
Surgical Technique Djv
A transnasal endoscopic approach starts by making a sphenoidotomy on the side of the tumor or, when it is in the midline opening, the side where the sinus is larger. The sphenoidotomy is opened up to the level of the skull base using a sphenoid punch. Suction diathermy will be needed to stop bleeding from the posterior branch of the sphenopalatine artery when opening the sphenoidotomy inferiorly Fig. 14.64 . Any vomerine spur should be removed. After carefully examining the CT scan and...
Surgical Anatomy Inb
The medial wall of the orbit is made up of the lamina papyracea of the ethmoid bone, the palatine bone, and more posteriorly the thicker bone of the sphenoid that makes up the apex of the orbit. The degree of pneuma-tization of the sphenoid sinus determines whether the optic nerve indents, or is even dehiscent in, its lateral wall. The same applies to the posterior ethmoid sinuses, which can envelop the optic nerve before it reaches the sphenoid sinus if there is a sphenoeth-moid cell. The...
Radiology
Teleradiology with electronic data transmission and the availability of online consulting between a radiologist and the ENT surgeon may help when a rapid second opinion is needed. Similarly, in this fast-growing field online surgery can be used as part of a distance-learning program. Fig. 16.4 The distribution of raised serum IgE in the general population. Fig. 16.4 The distribution of raised serum IgE in the general population. O Intermittent rhinitis O Persistent rhinitis Raised specific IgF...
Inflammatory Diseases
1 Pyogenic granuloma Fig. 6.33 . 2 Wegener granulomatosis Fig. 6.34a, b . 3 Sarcoidosis Fig. 6.35 a, b . Fig. 6.29 An edematous middle turbinate in a highly atopic patient. Allergic secretions can look like pus when they are lightly stained yellow by eosinophils. Fig. 6.29 An edematous middle turbinate in a highly atopic patient. Allergic secretions can look like pus when they are lightly stained yellow by eosinophils. Fig. 6.34a, b The crusting and granular mucosa show some of the spectrum of...
Surgical Anatomy 1
The anterior ethmoid artery is a branch of the ophthalmic artery and therefore it originates within the orbit before traveling medially through the bone of the anterior skull base the fovea ethmoidalis the part of the frontal bone that forms the roof of the ethmoid sinuses . It is normally enclosed to a large extent within a bony canal, but often part of this is very thin or dehiscent. It can often be located just behind the supraorbital cell that is an extension of the suprabullar recess Fig....
A Polypoidal Anterior End of the Middle Turbinate
It can sometimes be relatively difficult to differentiate middle meatal polyps from sessile polypoidal mucosa based on the middle turbinate as they can look the same Fig. 6.23a, b . It is wise to gently palpate any polyp in this area to help define whether it is based on the middle turbinate. The middle turbinate is a useful landmark and, as it is attached to the skull base, it is important not to avulse it. Polyps on the medial surface of the middle turbinate that do not come from the superior...
Indications Fcu
One of the most important aspects of this surgery is to first make sure that the primary pathology is due to distal obstruction of the nasolacrimal system Fig. 14.1a, b . If there is proximal obstruction, then surgery will fail. Often distal obstruction is mixed with a varying degree of proximal obstruction and this needs to be taken into consideration when counseling the patient about their expectations from surgery. Syringing and probing is the main way to define the site of obstruction. A...
Stammberger Sidebiting Punch Forceps
These essentially help to open a middle meatal an-trostomy inferiorly Fig. 10.24 . These are useful if an extensive ethmoidectomy has been done and it is desirable to lateralize the middle turbinate and open up the olfactory cleft. This particularly applies if there are polyps medial to the middle turbinate, either coming off it or off the septum. This creates an antrostomy with an exit that will be below the inferior level of the Fig. 10.21 a, b The Freer elevator is being used to gently...
Surgical Technique Kwh
A type III maxillary sinusotomy is undertaken initially and a thorough ethmoidectomy is done to expose the lamina papyracea. The lamina papyracea is readily incised in an oblique direction with a Freer's elevator Fig. 14.44a, b . Through-cutting forceps can be used to remove it sequentially inferiorly, superiorly, and posteriorly. During this procedure the assistant examines the eye to see that it does not move and ballottes it repeatedly to allow the surgeon to see how much of the lateral...
Frontal Recess Stenosis
Most frontal sinus disease is the result of previous surgery, and it is important not to instrument this area unless there is a good reason. The frontal sinus is often opaque on CT in nasal polyposis, but this is not a reason to operate on the frontal recess as it is normally due to retained mucus. It is rare to find polyps within the frontal sinus. Simply opening the middle meatus and debulking polyps in the region below the frontal recess with a shaver or through-cutting forceps, followed by...
Lesions of the Cribriform Plate and Fovea Ethmoidalis
Preoperative imaging to define the extent of the disease and in particular the extent of any intracranial involvement is vital. Surgery to resect lesions in this area should be done where there are the expertise and the facilities to do a craniotomy if necessary or to deal with any intracranial complications, although these should be rare. Otologists are familiar with the dura, both operating next to it and dealing with it when it is damaged. Rhinologists may be less comfortable dealing with...
Alternative Surgical Techniques Sdu
Some workers have advocated finding the sphenoid sinus from a lateral to medial approach by going through the posterior end of the superior turbinate. This can be done, but it runs the potential risk of going through the skull base or damaging the optic nerve if Fig. 5.74a Line diagram to represent the anterior aspect of the right sphenoid and posterior ethmoid sinuses. 1 Define the most posterior-superior-lateral part of the posterior ethmoid sinuses. 2 Move vertically downward and do not push...
References
Adelroth E, Rak S, Haahtela T, Aasand G, Rosenhall L, Zetterstrom O, Byrne A, Champain K, Thirlwell J, Della C 2000 Recombinant humanised mAb-E25, an anti-IgE mAb, in birch pollen-induced seasonal allergic rhinitis. Journal of Allergy and Clinical Immunology 106 2 253-259. Albritton FD, Kingdom TT, DelGaudio JM 2001 Malleable registration mask application of a novel registration method in image guided sinus surgery. American Journal of Rhinology 15 4 219-224. Anand VK, Kacker A 2000 Value of...
Nasal Polyps
The cause of most inflammatory polyps remains a mystery in spite of extensive work describing their cell morphology, IgE, and cytokine profiles Kramer et al., 2000 , as well as exploring some possible genetic associations Irving et al., 1997 . Why nasal polyps present more than twice as frequently in men is unknown. It is often said that polyps are caused by allergy, although atopy is no more prevalent in patients with nasal polyps than in the whole population Slavin, 1997 . However, a higher...
Surgical Technique 1
Once an uncinectomy has been done and the natural ostium has been identified, the ethmoid sinuses may be opened. It is safe to remove the sinuses that lie in a sagittal plane medial to the medial wall of the maxillary sinus N.B. The orbits are not two cones with their long axes in the sagittal plane, but they face slightly laterally with their medial walls lying parallel to the sagittal plane see Fig. 12.6 . . The bulla can be punctured with straight forceps, and as they are withdrawn their...
Surgical Technique Xxn
First of all, a type III maxillary sinusotomy is fashioned with its posterior limit extending level with the posterior wall of the maxillary sinus. This often means that the anterior branch of the sphenopalatine artery needs cauterizing. An anteriorly based mucosal flap over the frontal process of the maxilla and the anterior lacrimal crest is elevated to expose the anterior lacrimal crest. The anterior lacrimal crest is removed along its whole length using a Hajek-Kofler punch, and toward the...
Terminology and Classification Fxn
Sphenoethmoidectomy This is an extension of a partial anterior ethmoidectomy that involves surgery into the posterior ethmoid sinuses and the sphenoid sinus Fig.5.64 . l Vl 7,8 Fig. 5.64 A partial anterior ethmoidectomy with a posterior ethmoidectomy and sphenoid sinus surgery. Fig. 5.64 A partial anterior ethmoidectomy with a posterior ethmoidectomy and sphenoid sinus surgery. Fig. 5.65 a Endoscopic view and b CT scan of residual symptomatic polyps after oral and topical steroids. Fig. 5.65 a...
Alternative Surgical Techniques Lgl
1 The mucosa can be ablated with diathermy or laser, removed using power tools, or incised and reflected. 2 The bone can be ablated with a holmium laser, a Starpulse KTP laser, a chisel, forceps, or a drill. An external DCR can be done making a low Howarth incision. The sac is defined and retracted, with a rhinostomy being created into the nose. Flaps are then made from the sac, but these are difficult to suture to nasal mucosa because the sac itself gets in the way. The success rates reported...
Other Malignant Skull Base Tumors
There is, at present, little evidence that the endoscope is of benefit in resecting other malignant tumors affecting the skull base or paranasal sinuses, for example, adenocarcinoma Fig. 15.58a-f , squamous cell carcinoma Fig. 15.59 a-c , nasopharyngeal carcinoma, neuroendocrine tumors other than olfactory neuro-blastomas, lymphoma Quraishi et al., 2000 , undifferentiated carcinoma Fig. 15.60a-d , small-cell carcinoma, adenoid cystic carcinoma, sarcomas, and metastases. However, some malignant...
Partial Anterior Ethmoidectomy Terminology and Classification
Fig. 5.29 A line diagram showing the extent of a partial anterior ethmoidectomy. Fig. 5.29 A line diagram showing the extent of a partial anterior ethmoidectomy. Partial anterior ethmoidectomy involves an infun-dibulotomy including a partial resection of the anterior ethmoid air cells. The infundibulotomy can be extended to open the anterior ethmoidal cells, to the basal lamella, and to open the agger nasi air cells, but not to open them entirely as this would mean instrumenting the frontal...
Mucoceles
The majority of mucoceles can be marsupialized en-doscopically with minimal morbidity and with long-term results that are as good as, if not better than, those done by a conventional external approach. Concerns that the marsupialization of mucoceles may not halt their expansion have been found to be unwarranted. Mucoceles accessible with the endoscope should be opened as widely as possible using through-cutting forceps in order to minimize the amount of scar tissue that forms around the edges,...
Alternative Surgical Techniques
Occasionally, in a very narrow nose, where access is restricted by a narrow pyriform aperture, finding the maxillary ostia can be difficult, particularly if there is active purulent disease and a great deal of bleeding with any instrumentation in the middle meatus. While Fig. 5.19 a Zurich scissors or through-cutting forceps are used process. d A line diagram of c. e Blakesley forceps can be used to divide any remaining superior attachment of the uncinate to grasp the uncinate and rotate it...
Diagnosis
It is vital to localize the site of a leak Marshall et al., 2001a . Any fluid should be tested for immunofixation of beta-2-transferrin Fig. 15.9a, b . Consider whether there is an underlying high-pressure system. Successful closure depends on defining the exact site of any defect. No single technique works in all situations. The glucose oxidase test has a poor predictive value and gives too many false-positive results to be useful in making or excluding this important diagnosis Bateman and...
Malignant Melanoma
The management of malignant melanoma suggests that an initial en bloc resection with radiotherapy is associated with a lower local recurrence and meta-static rate in spite of its relatively low radiosensitivity. Fig. 15.55 a A right hemorrhagic polyp in the olfactory cleft an olfactory neuroblastoma. b Reconstructed coronal CT scan Fig. 15.55 a A right hemorrhagic polyp in the olfactory cleft an olfactory neuroblastoma. b Reconstructed coronal CT scan However, the prognosis is poor, with...
Indications 1
This is done for isolated anterior ethmoid and or maxillary sinus frontal sinus disease that has not responded to maximum medical treatment. It is worth limiting surgery to the anterior ethmoid sinuses before entering the frontal recess, because this is often all that is necessary. As soon as you instrument the frontal recess you greatly increase the risk of causing iatrogenic disease Kennedy, 1992 . If surgical treatment to the anterior ethmoid sinuses is followed by medical treatment, the...
Surgical Technique Ehg
The surgeon must have a good reason for operating in this area. The landmarks that will help you are the remains of the uncinate process, the remainder of the anterior wall of the ethmoid bulla, and a knowledge of the air cells from the CT scan. Follow the superior remnant of the uncinate process upward with a 45 through-cutting forceps. Now is the time to change to a 45 endoscope to examine the area and obtain an overview. Uncapped agger nasi cells, the terminal recess, and the ethmoid bulla...
Alternative Surgical Techniques Ves
Instead of creating a central drainage channel, it is possible to support and reconstruct the lateral wall of the frontal recess if collapse of that area is the primary problem Fig. 14.35 . This particularly applies when an external ethmoidectomy has led to a loss of bone lateral to the frontal recess. There is often a great deal of fibrosis in the area of the frontal recess when it has stenosed after an external ethmoidectomy. The old idea of using as large a stent as possible in the belief...
Indications Llh
Indications are extensive inverted papilloma affecting the lateral nasal wall and involving the maxillary sinus Fig. 14.54a, b and benign tumors of the medial wall of the maxilla. Fig. 14.54 a Endoscopic view and b axial CT scan showing recurrent inverted papilloma involving the anterior wall of the left maxilla. Fig. 14.54 a Endoscopic view and b axial CT scan showing recurrent inverted papilloma involving the anterior wall of the left maxilla.
Agger Nasi Air Cells
Endoscopically, it is possible to get an idea whether there is a sizable agger nasi cell from the prominence in the lateral nasal wall where it meets the middle turbinate Fig. 6.18a, b . Fig. 6.17 History and endoscopy are more reliable in assessment than CT after previous surgery. Endoscopic signs supported by a history suggestive of sinus pathology. Fig. 6.17 History and endoscopy are more reliable in assessment than CT after previous surgery. Endoscopic signs supported by a history...
Endoscopic Evidence of Mucosal Disease
Endoscopic findings must be interpreted in the light of patients' symptoms and response to medical treatment. You will be caught out if you intervene on the basis of an abnormal endoscopic examination alone. Fig. 6.11 An accessory ostium of the right maxillary sinus with clear mucus filling it. Fig. 6.11 An accessory ostium of the right maxillary sinus with clear mucus filling it. Fig. 6.13 The outflow area of the frontal recess. Fig. 6.13 The outflow area of the frontal recess. However,...
Surgical Technique Ksb
The posterior ethmoidal cells are entered through the basal lamella and it is safest to enter these medially and inferiorly Fig. 5.72 a-u . Enlarge access to these Fig. 5.67 A sphenoethmoid air cell above the sphenoid sinus note the optic nerve in its lateral wall arrow . Fig. 5.68 The sphenoid ostia can be seen high on the anterior wall of the sphenoid note that the bone becomes thin about 1 cm above the shoulder of the posterior choana. Fig. 5.68 The sphenoid ostia can be seen high on the...
Olfaction
The patient and surgeon often overlook the importance of sense of smell Simmen et al., 1999 . There are few reports on the incidence of the loss of sense of smell following endonasal surgery, but it may be as much as 1 Kimelman, 1994 Briner et al., 2003 . The patient who has a sense of smell often takes it for granted, but should it be lost, there are likely to be bitter recriminations. By assessing it, not only will you be able to document whether it is already absent or reduced, but you will...
Peroperative Complications Bleeding
Bleeding can be minimized by maximizing preoperative medical treatment and removing tissue with through-cutting forceps or a shaver to avoid tearing the mucosa. The other main causes of bleeding, besides those caused by a coagulopathy, are related to the sphenopalatine artery and the anterior ethmoidal artery. The anterior branches of the sphenopalatine artery come through the lateral nasal wall horizontally, just above the attachment of the inferior turbinate. If the middle meatal antrostomy...
A
Fig. 5.72 s Sinusotomy, type I. t Note the position of the septal branch of the sphenopalatine artery. u A line diagram to illustrate the size and position of a sphenoidotomy type I, the dark circle type II, the dark green vertical rectangle type III, the dark green horizontal rectangle. The sphenoid and the pale green box that represents a posterior ethmoid air cell are joined. The sphenoid can be opened more extensively but requires ligation of the sphenopalatine artery and an exact knowledge...
Access for Biopsies
It is important that all tissue, whether it looks harmless or not, is sent for histological examination. We found that 1 of 2021 nasal polyps had pathology that differed significantly from the clinician's diagnosis, and this then altered management Diamantopo-polous and Jones, 2000 . Endoscopic biopsy can reduce morbidity Trimas and Stringer, 1994 as well as preserving oncological barriers so that an en bloc resection can potentially be carried out without compromising oncological resection as...
Surgical Technique Pod
If the obstruction is due to soft tissue then it is possible to palpate it and see with an endoscope where it should be perforated and opened up. If there is a complete bony plate, it is important not to lose your way, and most surgeons initially find it safer to place their finger in the nasopharynx and aim the drill at it. It is now possible to visualize the posterior aspect of the septum and the back of the inferior turbinate and use these landmarks to drill through the atretic plate under...
Surgical Technique Qzr
A vertical incision is made through the mucosa over the posterior fontanelle, or a middle meatal an-trostomy is enlarged posteriorly to come near the posterior wall of the maxillary sinus. Then the mucosa is elevated to the crista ethmoidalis Fig. 14.19 a-h . The crista needs to be curetted away or drilled with a coarse diamond burr to expose the other branches. These branches vary in number and course. They are often convoluted. It helps to make a good wide plane between the mucosoperiosteum...
Osteoma
Approximately 3 of people have paranasal sinus osteomas according to Earwacker 1993 . In his series of 1500 CT scans, only two patients were symptomatic. This is the authors' experience. Many osteomas are found incidentally and are blamed for causing headaches or excision is recommended before they cause symptoms Hehar and Jones, 1997 . In practice, osteomas rarely cause any problems other than cosmetic. If they do cause symptoms by obstructing the frontal recess, their history should include...
Planning and Staging the Procedure
Stage the extent of the disease and decide on the procedure. After examining the scans, stage the extent of the radiological changes. Surgical time and a strategy can then be planned and tailored to match the extent of the disease. The most popular staging system has been described by Lund and Mackay 1993 Table 8.1 . Fig. 8.20 Sphenoid intersinus septum going to the carotid artery on both sides. Fig. 8.21 a An axial CT scan showing dehiscent optic nerves ies. c, d Sagittal CT scans show how in...
The Endoscopic Tour
The lateral nasal wall and cavity are inspected in three 1 Step 1 involves advancing the endoscope along the inferior meatus. If there is no room because of a septal spur, advance the endoscope between the middle and inferior turbinate toward the nasopharynx Fig. 6.4 . The posterior aspect of the nasal cavity is inspected before coming forward to inspect the front. The following structures should be examined the back of the inferior turbinate Fig. 6.5 , the tubal orifice, and the fossa of...
Surgical Anatomy Cmv
The nasal process of the frontal bone is thick and forms a beak that restricts both the anterior access to and drainage of the frontal sinus Fig. 14.26a, b . The frontal intersinus septum varies greatly in its position. The extent and direction of pneumatization vary more than in any other area of the paranasal sinuses. The frontal sinus often has more than one drainage channel. Pneumatized cells can travel up into the frontal bone in all directions anteriorly these form high agger Fig. 14.26 a...
Hemangioma
Most hemangiomas that appear in childhood involute spontaneously and no intervention is required. Occasionally they can enlarge, endangering vital structures, and then steroids or interferon alfa-2 have a role Ezekowitz et al., 1992 . Later in life, smaller capillary, venous, or cavernous hemangiomas can present, often with epistaxis. They can originate from the septum or the turbinates and alarm the patient and primary care physician, who may suspect malignancy. They can emulate pyogenic...
Alternative Surgical Techniques Mym
It is possible to approach the frontal recess anteriorly with a 0 scope if there is a large agger nasi air cell. A mucosal flap on the lateral nasal wall based anteriorly can be made so that the prominence in the lateral nasal wall created by the agger nasi air cell is uncovered. A Hajek-Kofler punch is then used to remove the armpit of this area where the middle turbinate Fig. 5.61 a An olive ended sucker or ball probe can be used to help define whether you have located the frontal sinus....